Infections After Prostate Biopsy Continue to Rise

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Patients are at higher risk of infections with the transrectal rather than transperineal approach.
Patients are at higher risk of infections with the transrectal rather than transperineal approach.

Infectious complication rates following prostate biopsies continue to increase despite decreased use of the procedures, a new study confirms.

Jim C. Hu MD MPH, of Weill Cornell Medical College in New York, and colleagues reported that the rates of infection within 30 days of prostate biopsy increased from 2.6% to 3.5% from 2011 to 2014 in New York State, based on data from patients of all ages and payment modalities. Complication rates were higher for transrectal than transperineal biopsies. Rates did not differ between initial and repeat biopsies.

Writing in The Journal of Urology (in press), Dr Hu's team said that although recent data have shown an increasing proportion of prostate biopsies for active surveillance, and, therefore, likely repeat procedures, “this cannot account for the ongoing trend, as repeat PNBx does not appear to carry an increased risk of complication, consistent with prior studies. More likely, higher infectious complications can be attributed to rising anti-microbial resistance, which has been documented both in the US and abroad.”

The study included 9472 men who underwent transrectal biopsy and 421 who underwent transperineal biopsy. In multivariable analysis, diabetes and recent hospitalizations each was associated with twice the risk of infections. The median cost of treating an infectious complication was $4,129.

The investigators found the transperineal approach to be protective. Compared with transperineal biopsy, transrectal biopsy was associated with nearly 3.5 times increased odds of infection.

“While the advantage of this approach must be weighed against costs and patient inconvenience, transperineal PNBx may offer an underutilized means of reducing complications on a national level, particularly among higher-risk patients such as diabetics or the immuno-compromised,” Dr Hu and colleagues wrote. No differences were found between approaches for urinary retention.

In line with findings from European studies, men with diabetes had nearly twice the risk of infections.

Use of targeted prophylaxis for appropriate patients needs to increase, the investigators stated. Clinicians employed targeted prophylaxis with pre-biopsy rectal swab and culture less than 1% of the time in the current study, although some underestimation may have occurred.

The most common reasons for prostate biopsy were elevated PSA and active surveillance, with abnormal digital rectal exam and atypia representing less than 5% of indications.

Commenting on the study, Franklin C. Lowe, MD, MPH, professor of urology at Albert Einstein School of Medicine in New York, stated that it has always been known that perineal biopsy of the prostate has a lower post-procedure infection rate than transrectal biopsy. “However, with the advent of transrectal ultrasound-guided biopsy, this became the preferred biopsy technique,” Dr Lowe told Renal & Urology News. “For many years the infection rate was low due to the use of ciprofloxacin prophylaxis. The increase in urinary infections and sepsis post transrectal biopsy are mainly due to the increased percentage of patients who have ciprofloxacin-resistant organisms.”

Consequently, Dr Lowe said, alterations in prophylaxis regimen are needed. Various changes include performing pre-biopsy rectal cultures to determine appropriate coverage; use of pre-biopsy betadine enemas; and adding an aminoglycoside or third-generation cephalosporin at the time of biopsy. Recent antibiotic usage, recent hospitalization, and diabetes mellitus are associated with increased risk of infection when only ciprofloxacin prophylaxis is used, he stated.

Reference

1.     Halpern JA, Sedrakyan A, Dinerman B, Hsu WC, Mao J, Hu JC, Indications, Utilization, and Complications Following Prostate Biopsy: a New York State Analysis, J Urol, doi: 10.1016/j.juro.2016.11.081. In press.

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